(Radiographics. 2001;21:E1-e1.)
© RSNA, 2001
Interventional Musculoskeletal Procedures1
Afshin Gangi, MD, PhD,
Stephane Guth, MD,
Jean-Louis Dietemann, MD and
Catherine Roy, MD
1 From the Department of Radiology B, University Louis Pasteur, University Hospital of Strasbourg, 1 Place de l'Hôpital, BP 426 - 67091 Strasbourg, France. Received September 10, 2000; accepted November 9. Address correspondence to A.G. (e-mail: gangi@rad6.u-strasbg.fr)
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Abstract
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Percutaneous interventional procedures for the musculoskeletal system are demonstrated and explained by means of a hypertext-based teaching file. The authors provide an overview of different procedures including musculoskeletal biopsy, percutaneous periradicular infiltration, diskography, percutaneous cementoplasty, percutaneous treatment of disk herniation, and percutaneous treatment of osteoid osteoma. The procedures are demonstrated with detailed illustration of materials used and computed tomographic and fluoroscopic images. The authors guide the user through each step of the procedures, with case studies that include indications, techniques, complications, and results.
Index Terms: Bone neoplasms, diagnosis, 40.312, 40.32, 40.33 • Bones, biopsy, 40.1261 • Bones, diseases, 40. 312, 40.20, 40.32 • Bones, surgery, 40.1261, 40.1267 • Computed tomography (CT), guidance, 30.1211, 40.1211 • Fluoroscopy • Osteoporosis, 40.56 • Spinal cord, neoplasms, 30.32, 30.33 • Spine, biopsy, 30.1261 • Spine, diseases, 30.25, 30.32, 30.33 • Spine, fixation devices, 30.1267 • Spine, interventional procedures, 30.1261, 30.1267 • Spine, intervertebral disks, 30.25, 30.783 • Spine, radiography, 30.123
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Biopsies of the Musculoskeletal System
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Introduction
Histopathologic and bacteriologic studies are often needed in musculoskeletal lesions to establish a definitive diagnosis. In such cases, percutaneous musculoskeletal biopsy (PMSB) has become a routine procedure. Advantages of PMSB compared with surgical biopsy include the following:
- No weakening of bone structures through surgical removal. This is particularly true in weight-bearing bones and in children, thus avoiding immobilization or osteosynthesis.
- No limitation of activity.
- No or minimal soft-tissue injury.
- No extensive hospitalization; procedure done on an outpatient basis.
- No general anesthesia; the PMSB can be easily performed under local anesthesia and neuroleptanalgesia.
- Minimal recovery time.
- No scars.
- Lower cost.
Indications and Contraindications
Indications
Percutaneous bone biopsy is performed whenever pathologic, bacteriologic, or biologic examination is required for diagnosis or treatment. The major indications are the following:
- Primary or secondary bone tumors
- Osteitis
- Septic arthritis, diskitis
Contraindications
The expected results of biopsy should be significant compared with the risks of the procedure. Careful review of imaging findings and of previous studies should assist the radiologist in avoiding unnecessary biopsies. Well-known contraindications are the following:
- Bleeding diatheses
- Biopsies of inaccessible sites (odontoid process, anterior arch of C1)
- Soft-tissue infection
Technique
Material
- Sterile drapes, tampons
- 22-gauge needle, scalpel (Fig 1)
- Surgical hammer (may be required)
- Biopsy needle (drilling device may be required) (Figs 2–4):
- 2-mm-diameter hand drill
- Or 14-gauge Bonopty penetration set (RADI Medical Systems, Uppsala, Sweden)
- Or 14-gauge bone Ostycut biopsy needle (Ostycut; Angiomed/Bard, Karlsruhe, Germany)
- Or 8-gauge trephine needle (Laredo type)
- Iodine, 1% lidocaine
Dual Guidance
Percutaneous musculoskeletal biopsy, like other interventional procedures, is usually performed with a single imaging technique: fluoroscopy or computed tomography (CT), each of which has advantages and drawbacks. Fluoroscopy offers multiple planes and direct imaging, with the disadvantages of poor soft-tissue contrast and nonnegligible radiation exposure for both patient and operator. CT is well-suited for precise interventional needle guidance because it provides good visualization of bone and surrounding soft tissues. It also avoids damage to adjacent vascular, neurologic, and visceral structures. The disadvantages of this method are the single plane and delayed imaging.
To address these concerns on a routine basis, a combination of CT and fluoroscopy for interventional procedures has been recommended (Fig 5). For fluoroscopy, a mobile C-arm is used, positioned in front of the CT gantry. With a rotating fluoroscope and CT, the structure to be punctured can be visualized three dimensionally and with exact differentiation of anatomic structures, which in many cases is not possible with fluoroscopy alone. Two mobile monitors are placed in front of the physician, displaying the last stored image and the fluoroscopic image. The operator can switch from CT to fluoroscopy and vice versa at any time.
In percutaneous biopsy, the intervention begins with CT and is continued with fluoroscopy. Fluoroscopy is associated with CT whenever drilling is necessary.
Pathway
A CT scan is performed to localize the lesion precisely. The entry point and the pathway (Fig 6) are determined with CT, avoiding nerve, vascular, and visceral structures.
- For peripheral long-bone biopsy, the approach has to be orthogonal to the bone cortex. This approach angle avoids slippage with the tip of the needle. For minimizing tissue lesions during pass through as much as possible, the shortest path should be chosen. The approach must avoid nerve, vascular, visceral, and tendinous structures and, if possible, muscular and, if not required, articular structures.
- For flat bones such as scapula, ribs, sternum, and skull we use an oblique approach angle of 30°-60°. This angle is a compromise. The tangential approach is preferred to avoid damage to underlying structures, whereas the orthogonal angle avoids slippage with the tip of the needle.
- For the pelvic girdle, we use a posterior approach, avoiding the sacral canal and nerves.
- For vertebral body biopsy, different approach routes can be selected depending on vertebral level (Figs 7–11): the anterior route for cervical level, the transpedicular and intercostovertebral route for the thoracic level, the posterolateral and transpedicular route for the lumbar level. For the neural posterior arch, we use a tangential approach to avoid damaging underlying neural structures.
Anesthesia and Bone Puncture
Bone biopsy is usually performed with the patient under local anesthesia (Fig 12). Neuroleptanalgesia may be necessary for painful lesions. General anesthesia is used only in children. The procedure is carried out under strict sterility. The skin, subcutaneous layers, muscles, and periosteum are infiltrated with anesthetic (1% lidocaine) with a 22-gauge needle (Fig 13). The position of the 22-gauge needle is checked with fluoroscopy and CT. For bone puncture, the biopsy needle is inserted safely under CT guidance. Fluoroscopy is used in conjunction with CT whenever drilling is necessary. Cortical perforation may require the aid of a surgical hammer (Fig 14).
Biopsy Needle and Bone Penetration
For peripheral bone biopsy:
- Subperiosteal or cortical lesions without ossification are directly punctured with a 14-gauge needle.
- In cases of mild ossification or a small cortex surrounding the lesion, we use a 14-gauge Ostycut bone biopsy needle and penetration is performed with a surgical hammer.
- In cases of mild condensation and for primary tumors or lymphoma, we use an 8-gauge trephine needle (Laredo type).
- In cases of dense ossification or dense cortical bone surrounding the lesion, drilling is necessary. In these cases, we use a 2-mm-diameter hand drill or a 14-gauge Bonopty penetration set. For vertebral body biopsies (Fig 15):
- We use an Ostycut bone biopsy needle, and penetration is carried out with a surgical hammer. We use a 14-gauge needle at the cervical, thoracic, and lumbar levels.
- In cases of mild condensation and for primary tumors or lymphoma we use an 8-gauge trephine needle (Laredo type).
- In cases of dense ossification surrounding the lesion, drilling is necessary. In these cases, we use a 2-mm-diameter hand drill or a 14-gauge Bonopty penetration set. For soft-tissue biopsies:
- True-cut 14- to 16-gauge needles are used (Temno; Allegiance Sante S.A., Maurepas, France)
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Figure 15a. Vertebral body biopsy. Drawings show (a) drilling with Bonopty penetration set, (b) Ostycut needle penetration performed with surgical hammer, and (c) drilling with trephine needle.
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Figure 15b. Vertebral body biopsy. Drawings show (a) drilling with Bonopty penetration set, (b) Ostycut needle penetration performed with surgical hammer, and (c) drilling with trephine needle.
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Figure 15c. Vertebral body biopsy. Drawings show (a) drilling with Bonopty penetration set, (b) Ostycut needle penetration performed with surgical hammer, and (c) drilling with trephine needle.
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Biopsy
CT images are repeated to confirm the correct placement of the needle tip (Fig 16). Sampling is then performed. For pathologic examination, the specimen is fixed in 10% formalin. Material is sent for histology. If bacteriologic analysis is necessary, the specimens are not fixed and are sent for culture.
Complications
Complications of PMSB are rare. Possible and reported complications include the following:
- The major complication is septic osteitis. To avoid this complication, strict sterility during the intervention is mandatory.
- Hematoma.
- Reflex sympathetic dystrophy.
- Neural and vascular injuries.
- Pneumothorax. Murphy et al (Murphy WA, Destouet JM, Gilula LA. Percutaneous skeletal biopsy: a procedure for radiologists. Radiology 1981; 139:545-549]), in a large review of 9,500 percutaneous skeletal biopsies, identified 22 complications (0.2%). They reported nine pneumothoraxes, three cases of menigitis, and five spinal cord injuries. Serious neurologic injury occurred in 0.08% of procedures. Death occurred in 0.02% of procedures. Only two complications were observed among our 180 patients. These consisted of paravertebral hematomas that resolved spontaneously. This low level of complications seems to be related to the systematic use of dual guidance, which provides precise and real-time control.
Data and Statistical Results
From 1987 to 1999, 180 percutaneous musculoskeletal biopsies were performed on an outpatient basis (Table 1). The patients (63% female, 37% male) ranged in age from 17 to 87 years (mean, 58.4 years). Only two complication were observed among our patients. These consisted of paravertebral hematomas that resolved spontaneously.
Specificity for diagnosis was 100%, sensitivity was 93.9%, positive predictive value was 100%, and negative predictive value was 87.5%.
Cases
Case 1. Osteolytic metastasis, with Ostycut needle used for biopsy (Fig 17).
Case 2. Lymphoma, transpedicular trephine biopsy (Fig 18).
Case 3. Diskitis, diskal biopsy (Fig 19).
Case 4. Osteitis of the femur, percutaneous biopsy with 8-gauge trephine needle (Laredo type) via orthogonal route (Fig 20).
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Figure 20a. Case 4. Osteitis of the femur. Percutaneous biopsy with 8-gauge trephine needle (Laredo type) via orthogonal route. (a) CT scan obtained before biopsy; (b-d) fluoroscopic guidance for (b) injection of anesthetic, (c) trephine drilling, (d) sampling; and (e) CT guidance for sampling.
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Figure 20b. Case 4. Osteitis of the femur. Percutaneous biopsy with 8-gauge trephine needle (Laredo type) via orthogonal route. (a) CT scan obtained before biopsy; (b-d) fluoroscopic guidance for (b) injection of anesthetic, (c) trephine drilling, (d) sampling; and (e) CT guidance for sampling.
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Figure 20c. Case 4. Osteitis of the femur. Percutaneous biopsy with 8-gauge trephine needle (Laredo type) via orthogonal route. (a) CT scan obtained before biopsy; (b-d) fluoroscopic guidance for (b) injection of anesthetic, (c) trephine drilling, (d) sampling; and (e) CT guidance for sampling.
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Figure 20d. Case 4. Osteitis of the femur. Percutaneous biopsy with 8-gauge trephine needle (Laredo type) via orthogonal route. (a) CT scan obtained before biopsy; (b-d) fluoroscopic guidance for (b) injection of anesthetic, (c) trephine drilling, (d) sampling; and (e) CT guidance for sampling.
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Figure 20e. Case 4. Osteitis of the femur. Percutaneous biopsy with 8-gauge trephine needle (Laredo type) via orthogonal route. (a) CT scan obtained before biopsy; (b-d) fluoroscopic guidance for (b) injection of anesthetic, (c) trephine drilling, (d) sampling; and (e) CT guidance for sampling.
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Case 5. Cervical vertebral biopsy via lateral approach. Diagnosis: eosinophilic granuloma (Fig 21).
Case 6. Osteolytic lesion of rib, percutaneous biopsy with Ostycut bone biopsy needle via oblique route. Diagnosis: myeloma (Fig 22).
Case 7. Osteolsclerotic lesion of the sternum, percutaneous biopsy with Ostycut bone biopsy needle via oblique route. Diagnosis: breast cancer metastasis (Fig 23).
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Figure 23a. Case 7. Breast cancer metastasis. Percutaneous biopsy with Ostycut bone biopsy needle via oblique route. (a) CT scan of osteosclerotic lesion and (b) CT guidance for biopsy.
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Figure 23b. Case 7. Breast cancer metastasis. Percutaneous biopsy with Ostycut bone biopsy needle via oblique route. (a) CT scan of osteosclerotic lesion and (b) CT guidance for biopsy.
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Case 8. Cervical vertebral biopsy via anterolateral approach. Diagnosis: myeloma (Fig 24).
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Diskography
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Introduction
Low back pain is one of the most common disorders; however, the etiology of low back remains one of the most complex problems. Conventional imaging modalities such as plain radiography, CT, and magnetic resonance (MR) imaging are effective and, in many cases, sufficient diagnostic modalities. These modalities are, however, only morphologic. Diskography with the "memory pain test" is the only method that permits physiopathologic and morphologic exploration of low back pain. Therefore, diskography has a useful but limited role in the exploration of low back pain.
Indications and Contraindications
Indications
- Clinical signs of radiculopathy with inconsistent, negative, or equivocal CT, MR imaging, or myelographic findings.
- Performed before percutaneous laser disk decompression (PLDD), to prove that a disk herniation is contained.
Contraindications
- Diskography is an invasive technique and must not be used as a screening tool.
- Nerve paralysis due to disk herniation.
- Hemorrhagic diathesis.
- Local infection of cutaneous, subcutaneous, or muscle layers.
Material
- 22-gauge needle, 12.5-20 cm long
- 18-gauge, 9.5-cm needle at lumbar level
- Local anesthesia with 1% lidocaine
- Contrast medium (Omnipaque 180)
- 5-mL syringe and sterile connecting tube
- Iodine, sterile drapes
Technique
Puncture
The procedure is started with sterile preparation of the skin with an aseptic (iodine). The subcutaneous layers and lumbar muscles are infiltrated with local anesthetic (1% lidocaine) with a 22-gauge 9-cm-long needle. The position of the needle is checked with fluoroscopy and CT (Fig 25).
- Cervical level: The patient is placed in the supine position, head slightly turned and in hyperextension. The entry point and pathway are determined with CT. After local anesthesia of the skin, a 22-gauge 9.5-12.5-cm spinal needle is placed via an anterolateral approach in the center of the disk under dual CT and fluoroscopic guidance. Under precise CT guidance, puncture of the carotid artery is avoided.
- Lumbar level: The patient is placed in the prone position. The entry point and pathway are determined with CT. The subcutaneous layers and lumbar muscles are infiltrated with local anesthetic (1% lidocaine) with a 22-gauge 9-cm-long needle. The tip of the 18-gauge needle is positioned to reach the articular process and its placement is checked with fluoroscopy and CT. The stylet of this needle is then removed and a 22-gauge 20-cm stylet is inserted into the 18-gauge needle. The tip of the 22-gauge spinal needle is placed in the center of the disk. The position of the needle is checked with fluoroscopy and CT.
Contrast Agent Injection and Memory Pain Test
We inject 1-2 mL of contrast agent at the lumbar level and 0.3-0.5 mL at the cervical level (Fig 26). The patient is asked to describe pain reproduction and radiation during injection. Memory pain is positive if injection reproduces the patient's leg or back pain.
Complications
Complications of diskography are rare. The major complication is septic diskitis. To prevent this complication, strict sterility during the intervention is mandatory. No complications were observed among our patients.
Cases
Case 1. Diskography at L4-L5 level; memory pain test negative (Fig 27).
Case 2. Diskography at cervical level (Fig 28).
Case 3. Diskography at L5-S1 level; memory pain test negative (Fig 29).
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Percutaneous Periradicular Steroid Injection
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Introduction
The lumbar portion of the spine causes pain, suffering, and disability more frequently than any other part of the body. In the past 20 years, the growing crisis of disability resulting from low back pain has led to the recognition that the problem cannot be solved by better or more frequent surgery. Some minimally invasive interventional procedures are available to relieve pain and to minimize the risk of disability. These procedures offer multiple possibilities for lumbosacral pain control associated, according to need, with conventional pain therapies. Nerve root inflammations seems to be responsible for low back pain and sciatica. Percutaneous periradicular infiltration (PPRI) is an injection of steroids and anesthetic into the epidural space at the level of the pathologic disk.
Principle
There is no clear single explanation as to why a disk rupture causes back pain or sciatica or both (Figs 30, 31). Some disk ruptures remain asymptomatic. The patient’s major complaint is usually pain. However, physical pressure on a peripheral nerve alone does not produce pain; it produces paresthesia. In examining this problem further, at the conclusion of routine laminectomy for herniated nucleus pulposus, MacNab (JA McCulloch, EE Transfeldt. MacNab's backache. 3rd ed. Philadelphia, Pa: Lippincott, Williams & Wilkins, 1997; 227-230) placed a Fogarty catheter beneath the emerging nerve root of a segment above the laminectomy level. When the patient regained consciousness and before being given any analgesics, the catheter was distended. It was found that although distention of the catheter beneath an involved, red, inflamed nerve root reproduced the sciatic pain, distention of the catheter beneath a normal nerve root produced paresthesia only. It is likely that there are neuromechanical factors involved in explaining the mechanism of symptom production in a herniated nucleus pulposus. Periradicular injection of long-acting steroids is an efficient therapy, probably because it decreases inflammation of the epidural space.
Indications
The major indications for PPRI are
- Treatment of acute low back pain of diskogenic origin (without nerve paralysis) resistant to conventional medical therapy.
- Postdiskectomy syndrome.
Technique
The procedure is performed on an outpatient basis. The patient is placed prone on the CT table. A CT scan of the affected level allows precise choice of needle pathway. For this procedure, we use only CT guidance.
Lumbar level. The patient is placed in prone position. The entry point and pathway are determined with CT. After local anesthesia of the skin, a 22-gauge spinal needle is placed under CT guidance via a posterior approach near the painful nerve root. In intracanalar infiltration, absence of cerebrospinal fluid (CSF) is verified by aspiration. Once the needle is in the epidural space (Fig 32), 1.5 mL of air is injected (Fig 33) to confirm the extradural position of the needle tip. Then 2-3 mL of a long-acting steroid solution (cortivazol, 3.75 mg is injected (Fig 34), pure or mixed with a solution of 0.5% lidocaine (2 mL). Under precise CT guidance, dural sac perforation is avoided. However, if the dura is perforated because of an adhesion of the dural sac to the ligamentum flavum or because of a mistaken maneuver, the needle must be pulled back slightly and checked by aspiration for CSF. If there is none, the corticosteroid solution is injected without anesthetic. During injection, the patient may experience a spontaneous recurrence of pain lasting a few seconds, brought on by dural stretch.
Cervical level. The patient is placed in the supine position, head slightly turned and in hyperextension. The entry point and the pathway are determined with CT. After local anesthesia of the skin, a 22-gauge spinal needle is placed near the painful nerve root via a lateral approach under CT guidance. Then 2-3 mL of cortivazol solution is injected. Under precise CT guidance, vertebral artery injury and intraarterial injection are avoided.
Complications
Complications of PPRI under CT guidance are rare:
- Meningitis with neurologic damage (quadriplegia, multiple cranial nerve palsies, nystagmus) has been described after epidural or intrathecal injection of steroids if strict sterility is not respected. With precise CT monitoring, accidental intrathecal injection can be avoided. Strict sterility during the intervention is mandatory.
- There is a risk of calcifications with use of triamcinolone hexacetonide as a long-acting steroid. We do not recommend use of this steroid.
- At the cervical level, vertebral artery injury and intraarterial injection have been described. This can be avoided with precise CT guidance.
Results
Over 6 years, 186 periradicular injections were performed under CT guidance. The short-term benefits of PPRI include good pain relief in 78% of extraforaminal herniations and in 65% of herniations in other locations. The long-term result was satisfactory (persistence of relief for at least 6 months) in PPRI of extraforaminal herniations only: 68% had good results 2 years after the PPRI (average of three injections). Strict sterile technique limits the risk of infection. With precise CT monitoring, accidental intrathecal injection can be avoided. We had no complications in our series.
Cases
Case 1. PPRI at lumbar level for disk herniation and leg pain (Fig 35).
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Figure 35a. Case 1. PPRI at lumbar level for disk herniation and leg pain. (a) CT scan shows disk herniation. (b) Needle is placed in epidural space under CT guidance for (c) gaseous epidurography and steroid injection. (d) Epidurography shows disk after procedure.
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Figure 35b. Case 1. PPRI at lumbar level for disk herniation and leg pain. (a) CT scan shows disk herniation. (b) Needle is placed in epidural space under CT guidance for (c) gaseous epidurography and steroid injection. (d) Epidurography shows disk after procedure.
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Figure 35c. Case 1. PPRI at lumbar level for disk herniation and leg pain. (a) CT scan shows disk herniation. (b) Needle is placed in epidural space under CT guidance for (c) gaseous epidurography and steroid injection. (d) Epidurography shows disk after procedure.
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Figure 35d. Case 1. PPRI at lumbar level for disk herniation and leg pain. (a) CT scan shows disk herniation. (b) Needle is placed in epidural space under CT guidance for (c) gaseous epidurography and steroid injection. (d) Epidurography shows disk after procedure.
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Case 2. PPRI at cervical level for disk herniation (Fig 36).
Case 3. PPRI at lumbar level for disk herniation and leg pain (Fig 37).
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Figure 37a. Case 3. PPRI at lumbar level for disk herniation and leg pain. (a) Needle is placed in epidural space under CT guidance for (b) gaseous epidurography and steroid injection. (c) Epidurography shows disk after procedure.
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Figure 37b. Case 3. PPRI at lumbar level for disk herniation and leg pain. (a) Needle is placed in epidural space under CT guidance for (b) gaseous epidurography and steroid injection. (c) Epidurography shows disk after procedure.
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Figure 37c. Case 3. PPRI at lumbar level for disk herniation and leg pain. (a) Needle is placed in epidural space under CT guidance for (b) gaseous epidurography and steroid injection. (c) Epidurography shows disk after procedure.
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Case 4. PPRI at cervical level for disk herniation (Fig 38).
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Percutaneous Laser Nucleotomy
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Introduction
The long-term outcome, the complications and suboptimal results that may accompany open disk surgery have led to the early development of other treatment techniques that avoid a surgical approach through the spinal canal and extensive disk ablation. Percutaneous removal of nucleus pulposus has been performed with a variety of chemical and mechanical techniques over the past several years. These techniques consist of removing all or part of the nucleus pulposus to induce more rapid healing of the pathologic lumbar disk (Figs 30, 39). Percutaneous nucleotomy is now widely used, as it is much less invasive than surgical diskectomy. To date, the most promising of these minimally invasive therapies used for treatment of disk herniation is percutaneous laser disk decompression (PLDD).
Principle
The advantage of this percutaneous technique is to reduce volume and pressure of the pathologic disk without damage to other spinal structures. All minimally invasive techniques such as PLDD are based on the reduction of volume of the pathologic disk. In this procedure, laser energy is transmitted through a thin optical fiber into the intervertebral disk (Fig 40). The aim of PLDD is to vaporize a small portion of the nucleus. The ablation of this relatively small volume results in an important reduction of intradiskal pressure, thus reducing disk herniation (Fig 41).
Advantages of PLDD
This minimally invasive technique avoids the drawbacks of classical surgery:
- No significant soft-tissue injury; no risk of fibrosis
- No extensive hospitalization; performed on outpatient basis
- No general anesthesia; can easily be performed under local anesthesia
- Minimal recovery time (6 weeks or less)
- No scars
- Lower costs (25%-30% of surgical treatment costs)
Indications and Contraindications
Indications. Patient selection is crucial for treatment effectiveness. Patients should have contained disk herniations that (a) are determined with CT or MR imaging, (b) have positive and consistent neurologic findings (leg pain of greater intensity than back pain, positive straight-leg-raising test, decreased sensation, normal motor response and tendon reflex), and (c) have not responded to 6 weeks of conservative therapy
Contraindications. The contraindications are nerve paralysis, hemorrhagic diathesis, spondylolisthesis, spinal stenosis, previous surgery at the same level, significant psychologic disorders, substantial narrowing of the disk space, workplace injuries with monetary gain, local infection of cutaneous, subcutaneous, or muscular layers.
Technique
Placement
The patient is placed in a prone position on the CT table. To open up the posterior aspect of the disk space, rolls are placed under the abdomen to position the lumbar spine in a semiflexed position. This is particularly helpful at the L5-S1 level. The entry point and pathway are determined with CT, avoiding the nerve root and visceral structures (Fig 42). At the L5-S1 level curved needles are usually necessary.
Material (Fig 43)
- Diode laser (Diomed, Cambridge, England) and a neodymium:yttrium-aluminum-garnet (Nd:YAG) 1064-nm wavelength laser (LaserSonics, Milpitas, Calif)
- Optical fiber, Y connector
- 22- and 18-gauge needles, scalpel
- Iodine, 1% lidocaine
- Sterile drapes, tampons
Guidance
PLDD is performed under dual guidance with CT and fluoroscopy (44). Two mobile fluoroscopy monitors are placed in front of the physician along with a CT monitor. At any time, the operator can switch from CT to fluoroscopy and vice versa. Once the entry point is determined with CT, a lateral fluoroscopy view is obtained at the desired disk level. In this way, the operator can visualize the pathway and the correct angulation of the needle. In most of the cases, the angulation is oblique in the three planes, especially at the L5-S1 level.
Local Anesthesia
The procedure is done under strict sterility. The subcutaneous layer, lumbar muscles, and articular process are infiltrated with local anesthetic (1% lidocaine) with a 22-gauge, 9-cm-long needle (Fig 45). The position of the needle is checked with fluoroscopy and CT (Fig 46).
Disk Puncture
A short scalpel incision is made in the skin (Fig 47). Through the skin incision the 18-gauge needle is inserted parallel to the 22-gauge needle under continuous lateral fluoroscopic guidance (Fig 48). The tip of the 18-gauge needle must reach the posterior part of the nucleus pulposus. The patient must be monitored for pain during the whole intervention, and the needle must be repositioned if radicular pain occurs. To confirm contained disk herniation, diskography can be performed just before PLDD.
Opical Fiber Check and Placement
The optical fiber is first checked (Fig 49a). Before the optical fiber is placed, it is inserted into an 18-gauge needle mounted with a side-arm fitting to measure the appropriate length of the fiber (Fig 49b–49d). The distal part of the fiber should extend 5 mm beyond the needle tip. The proper length of the fiber is indicated with a sterile strip to avoid excessive advancement of the fiber. After the stylet of the 18-gauge needle is removed, the optical fiber is inserted into the disk (Fig 50). The distal part of the optical fiber should continue to extend 5 mm beyond the needle tip.
Laser Ablation of Disk
When satisfactory needle position is obtained, the laser procedure begins (Fig 51a). The laser produces 15-20 W of power with 0.5-1-second pulses at 4-10-second intervals, depending on patient comfort. Recommended laser doses for PLDD range from 1,200 to 1,500 J for the L1-L2, L2-L3, L3-L4, and L5-S1 levels and 1,500 to 2,000 J for L4-L5. Use of this technique with these short exposure times results in no heating of adjacent bone structures. A CT scan is performed at the disk level every 200 J to visualize the vaporized area (Fig 51b). The patient must be able to communicate and respond to pain during the entire procedure. General anesthesia is therefore absolutely contraindicated. If pain occurs, the intervals between pulses are increased and aspiration is applied to reduce pressure within the disk.
Follow-up
For 2 weeks after the intervention, athletic activities and positions that could induce hyperkyphosis should be restricted. Resolution of leg pain is usually obtained within 1 week to 2 months (Fig 52). The two most critical elements to successful PLDD are proper patient selection and correct needle placement.
Complications
Complications of PLDD under CT and fluoroscopic guidance are rare:
- The major complication of PLDD is septic diskitis. To prevent this, strict sterility during the intervention is mandatory.
- Thermic aseptic diskitis can result in severe backache for 3-6 months.
- Disk herniation or free fragment evacuation can recur with associated leg pain.
Results
From 1987 to 1997, 169 patients with herniated lumbar disk and radicular pain were treated with PLDD on an outpatient basis. There were 93 male and 76 female patients; the oldest was 71 years old, and the youngest was 12 years old (mean age, 42 years). The longest follow-up period was 6 years; the average follow-up time was 19 months. The locations of the herniations were L5-S1 (87 cases), L4-L5 (71 cases), and L3-L4 (11 cases). MacNab criteria (Table 2) were used to grade the response to treatment. The overall success rate was 76% according to MacNab's criteria, with 55.6% having good results and 20.2% having fair results. In four cases, PLDD was performed at two levels. Eleven patients with poor results or recurrence were later treated surgically, with a success rate of 68%. After 6-12 months, a reduction of disk herniation was observed at CT or MR imaging. These cases were evaluated a second time, with a mean follow-up time of 53 months; the long-term results were identical. Complications of PLDD under CT and fluoroscopic guidance are rare. The major complication is septic diskitis. One patient had a spondylodiskitis. Another had severe backache due to an aseptic diskitis for 6 weeks (3 years follow-up). One patient was readmitted 24 hours after PLDD with severe recurrence of leg pain due to free fragment evacuation with upward migration. These data are encouraging for substantiating the validity of percutaneous laser nucleotomy for contained lumbar disk herniation. The two most critical elements in successful PLDD are proper patient selection and correct needle placement. Further random comparative studies are necessary to confirm these data; however, PLDD is a valuable, minimally invasive alternative to conventional surgery for treating disk herniation.
Cases
Case 1. PLDD for disk herniation with leg pain. Satisfactory results of laser vaporization under CT guidance were obtained, with air filling the herniation (Fig 53). There were no complications and good clinical results.
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Figure 53a. Case 1. PLDD for disk herniation with leg pain. (a) CT scan show needle path. (b, c) Disk puncture is performed under (b) CT and (c) fluoroscopic guidance. (d) Laser vaporization is performed under CT guidance; (e) CT scan shows laser vaporization gas (arrow) inside disk herniation.
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Figure 53b. Case 1. PLDD for disk herniation with leg pain. (a) CT scan show needle path. (b, c) Disk puncture is performed under (b) CT and (c) fluoroscopic guidance. (d) Laser vaporization is performed under CT guidance; (e) CT scan shows laser vaporization gas (arrow) inside disk herniation.
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Figure 53c. Case 1. PLDD for disk herniation with leg pain. (a) CT scan show needle path. (b, c) Disk puncture is performed under (b) CT and (c) fluoroscopic guidance. (d) Laser vaporization is performed under CT guidance; (e) CT scan shows laser vaporization gas (arrow) inside disk herniation.
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Figure 53d. Case 1. PLDD for disk herniation with leg pain. (a) CT scan show needle path. (b, c) Disk puncture is performed under (b) CT and (c) fluoroscopic guidance. (d) Laser vaporization is performed under CT guidance; (e) CT scan shows laser vaporization gas (arrow) inside disk herniation.
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Figure 53e. Case 1. PLDD for disk herniation with leg pain. (a) CT scan show needle path. (b, c) Disk puncture is performed under (b) CT and (c) fluoroscopic guidance. (d) Laser vaporization is performed under CT guidance; (e) CT scan shows laser vaporization gas (arrow) inside disk herniation.
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Case 2. PLDD with satisfactory results (Fig 54). Note air filling the disk herniation. There were no complications and good clinical results.
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Figure 54a. Case 2. PLDD for disk herniation. (a, b) Disk puncture is performed under (a) CT and (b) fluoroscopic guidance. (c) Laser vaporization is performed under CT guidance: (d) laser vaporization (red arrow), gas filling annular tear (blue arrow), and gas filling disk herniation (yellow arrow).
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Figure 54b. Case 2. PLDD for disk herniation. (a, b) Disk puncture is performed under (a) CT and (b) fluoroscopic guidance. (c) Laser vaporization is performed under CT guidance: (d) laser vaporization (red arrow), gas filling annular tear (blue arrow), and gas filling disk herniation (yellow arrow).
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Figure 54c. Case 2. PLDD for disk herniation. (a, b) Disk puncture is performed under (a) CT and (b) fluoroscopic guidance. (c) Laser vaporization is performed under CT guidance: (d) laser vaporization (red arrow), gas filling annular tear (blue arrow), and gas filling disk herniation (yellow arrow).
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Figure 54d. Case 2. PLDD for disk herniation. (a, b) Disk puncture is performed under (a) CT and (b) fluoroscopic guidance. (c) Laser vaporization is performed under CT guidance: (d) laser vaporization (red arrow), gas filling annular tear (blue arrow), and gas filling disk herniation (yellow arrow).
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Case 3. PLDD with good clinical results and no complications (Fig 55).
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Figure 55a. Case 3. PLDD for disk herniation. (a) CT scan shows disk herniation. (b, c) Disk puncture is performed under (b) CT and (c) fluoroscopic guidance. (d) Laser vaporization is performed under CT guidance.
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Figure 55b. Case 3. PLDD for disk herniation. (a) CT scan shows disk herniation. (b, c) Disk puncture is performed under (b) CT and (c) fluoroscopic guidance. (d) Laser vaporization is performed under CT guidance.
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Figure 55c. Case 3. PLDD for disk herniation. (a) CT scan shows disk herniation. (b, c) Disk puncture is performed under (b) CT and (c) fluoroscopic guidance. (d) Laser vaporization is performed under CT guidance.
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Figure 55d. Case 3. PLDD for disk herniation. (a) CT scan shows disk herniation. (b, c) Disk puncture is performed under (b) CT and (c) fluoroscopic guidance. (d) Laser vaporization is performed under CT guidance.
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Interstitial Laser Photocoagulation of Osteoid Osteoma
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Introduction
Osteoid osteoma is a benign neoplasm of bone and occurs more often in men. The age range is from 2 to 50 years, but 90% of these tumors occur before the age of 25 years. Osteoid osteoma produces local pain that is worse at night and improves dramatically with aspirin. The characterisic findings for this tumor in clinical and radiologic examinations can in many instances lead to a high level of diagnostic confidence. Treatment consists of complete removal of the nidus. Conventional treatment is surgical or percutaneous excision. The ability to precisely control the treated area, a high degree of precision, applicability in joints, and excellent dose-reponse characteristics make interstitial laser photocoagulation (ILP) a valuable treatment method for osteoid osteoma.
Principle
ILP consists of percutaneous insertion of optical fibers into the tumor (Fig 56). The tumor is coagulated and destroyed by direct heating. With a low-power laser technique, a well-defined coagulation volume of predictable size and shape can be obtained in bone tissue. Experimental histopathologic examinations have evaluated the mean diameter of coagulation produced by an 805-nm diode laser using 400-µm polymer-clad fiber with a constant power of 2 W. The mean diameter of coagulation varies from 3.5 mm with a dose of 200 J, 5 mm with 400 J, 6 mm with 600 J, 7.5 mm with 800 J, and 9 mm with 1,000 J in the femurs of pigs. The diameters of coagulation increased significantly, with lesions of 16 mm in diameter at 1,200 joules. We speculated that cellular damage could occur that would be too subtle to detect at histologic examination immediately after injury. This experimental work has shown that a reproducible area of coagulative necrosis is obtained around the fiber, with good correlation between energy delivered and lesion size and with conservation of the biomechanical properties of the bone tissue in the treated area (Fig 57). The size of osteoid osteomas falls within the range that can be effectively coagulated by one or two fibers.
Advantages of ILP
Advantages of ILP compared with surgical or percutaneous excision:
- No weakening of bone structures through surgical removal; this is particularly important in weight-bearing bones and in children. No need of immobilization or osteosynthesis. No limitation of activity.
- Applicability in joints
- No extensive hospitalization; ambulatory procedure
- No general anesthesia in adults; ILP can easily be performed under local anesthesia and neuroleptanalgesia (general anesthesia is needed for children).
- Minimal recovery time
- No scars
- Cost-effective
Indications and Contraindications
Indications. Patient selection is crucial for treatment effectiveness. The indications are osteoid osteomas determined with CT or MR imaging and scintigraphy that have positive and consistent clinical findings.
Contraindications. Hemorrhagic diathesis and lesions near neurologic structures (distance, <5 mm).
Technique
Material (Figs 2, 43a 58)
- Diode laser (Diomed) for IPL
- 400-µm precharred optical fiber, Y connector
- Sterile drapes, tampons
- 22- and 18-gauge needles, scalpel
- A drilling device: 2-mm-diameter hand drill or 14-gauge Bonopty penetration set (RADI Medical Systems) or 14-gauge bone Ostycut biopsy needle (Angiomed/Bard)
- Iodine, 1% lidocaine
Bone Puncture
A CT scan is obtained to locate the tumor precisely. CT is used to measure the diameter of the nidus. The longest diameter of the nidus determines the energy that will be necessary to coagulate the tumor. For diameters larger than 10 mm, we usually use two fibers to ensure tumor destruction. The entry point and the pathway are determined with CT (Fig 59), avoiding nerve, vascular, and visceral structures. The penetration of the needle into the nidus is always extremely painful; therefore, ILP is performed under neuroleptanalgesia (Fig 60). General anesthesia is used in children. The procedure is performed under strict sterility. The skin, subcutaneous layers, muscles, and periosteum are infiltrated with local anesthetic (1% lidocaine) with a 22-gauge needle. The position of the needle is checked with fluoroscopy and CT. The 18-gauge needle is inserted safely under CT guidance. Fluoroscopy is used in conjunction with CT whenever drilling is necessary.
Bone Drilling
The tip of an 18-gauge needle must be placed into the central part of the nidus. Sometimes bone drilling is required to reach the nidus (Fig 61) depending on perilesional hyperostosis.
- Subperiosteal nidi or cortical nidi without major ossification are directly punctured with an 18-gauge spinal needle (Becton Dickinson, Rutherford, NJ).
- In cases with mild ossification or a small cortex surrounding the lesion, a 14-gauge bone biopsy needle (Ostycut) is adequate.
- In cases of dense ossification or of dense cortical bone surrounding the lesion, drilling is necessary. In these cases we use a 2-mm-diameter hand drill or a 14-gauge Bonopty penetration set to allow insertion of the 18-gauge needle.
Optical Fiber Placement
The 18-gauge needle tip is inserted into the center of the nidus. Before the optical fiber is placed, it is inserted into another identical 18-gauge needle mounted by a side-arm fitting to measure the appropriate length of the fiber (Fig 49). The 400-µm precharred fiber is then inserted through the needle (Fig 49), and the needle is withdrawn about 5 mm so that the tip of the bare fiber lies within the center of the tumor.
Laser Photocoagulation
The diode laser (805nm) is turned on in continuous-wave mode at a power of 2 W for 200-500 seconds, depending on nidus size (energy delivered, 400-1,000 J). CT guidance scans are obtained during the procedure to detect vaporization gas (Fig 62).
Follow-up
After a period of 6-12 months, sclerosis of the nidus is observed on CT scans (Fig 63). Return to normal activities is usually prompt; most patients were able to return to work or school within a week.
Complications
Complications of ILP are rare:
- The major complication of ILP is septic osteitis. To prevent this complication, strict sterility during the intervention is mandatory.
- Hematoma
- Reflex sympathetic dystrophy
- Recurrence of osteoid osteoma. Only one complication was observed among our 55 patients. This consisted of a mild reflex sympathetic dystrophy of the wrist. One week after the procedure, this patient reported a burning pain completely different from the previous sensations. The patient described new symptoms consisting of the burning pain, hyperalgesia, hyperesthesia, and vasomotor and sudomotor disturbances. These symptoms were entirely relieved after 2 months of treatment.
Results
From 1993 to 1998, 55 patients with osteoid osteoma were treated with ILP on an outpatient basis or with 24 hours of hospitalization. Patients ranged in age from 5 to 48 years. ILP was successful in 50 patients (91% success rate). Follow-up ranged from 12 to 56 months (mean, 47 months). Pain relief was observed to occur rapidly: 26 patients (52%) were completely pain free within 24 hours of the procedure, 49 (98%) were pain free within 48-72 hours, and one patient was pain free only after 2 months because of a reflex sympathetic dystrophy syndrome. Twenty-four patients (48%) were discharged on the day of the intervention and had a moderate amount of pain until the next day, controlled with oral analgesics. Twenty-six patients (52%) had substantial local pain and were hospitalized overnight for treatment with narcotics; they were discharged on a regimen of oral medication within 24 hours of the procedure. The return to normal activities was prompt: Most patients were able to return to work or school within a week. Treatment was unsuccessful in five patients. In one patient, ILP was not performed because of the patient's agitation. In four patients, pain recurred after variable pain-free periods ranging from 6 weeks to 1 year; CT examination revealed remaining nidus.
Cases
Case 1. Osteoid osteoma of the tibia treated with percutaneous ILP (Fig 63).
Case 2. Intraarticular osteoid osteoma of the femoral neck treated with percutaneous ILP (Fig 64).
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Figure 64a. Case 2. Intraarticular osteoid osteoma of the femoral neck. CT scans show (a) osteoid osteoma, (b) ILP procedure, (c) nidus immediately after ILP, and (d) nidus 6 months after ILP.
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Figure 64b. Case 2. Intraarticular osteoid osteoma of the femoral neck. CT scans show (a) osteoid osteoma, (b) ILP procedure, (c) nidus immediately after ILP, and (d) nidus 6 months after ILP.
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Figure 64c. Case 2. Intraarticular osteoid osteoma of the femoral neck. CT scans show (a) osteoid osteoma, (b) ILP procedure, (c) nidus immediately after ILP, and (d) nidus 6 months after ILP.
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Figure 64d. Case 2. Intraarticular osteoid osteoma of the femoral neck. CT scans show (a) osteoid osteoma, (b) ILP procedure, (c) nidus immediately after ILP, and (d) nidus 6 months after ILP.
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Case 3. Recurrent osteoid osteoma of the humerus after surgical treatment and pathologic fracture, treated with percutaneous ILP (Fig 65).
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Figure 65a. Case 3. Recurrent osteoid osteoma of the humerus after surgical treatment and pathologic fracture. (a) CT scan and (b) radiograph show osteoid osteoma. (c) CT scan obtained during ILP.
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Figure 65b. Case 3. Recurrent osteoid osteoma of the humerus after surgical treatment and pathologic fracture. (a) CT scan and (b) radiograph show osteoid osteoma. (c) CT scan obtained during ILP.
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Figure 65c. Case 3. Recurrent osteoid osteoma of the humerus after surgical treatment and pathologic fracture. (a) CT scan and (b) radiograph show osteoid osteoma. (c) CT scan obtained during ILP.
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Case 4. Osteoid osteoma of thoracic spine (T7) treated with percutaneous ILP (Fig 66).
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Figure 66a. Case 4. Osteoid osteoma of thoracic spine (T7). (a) CT scan and (b) scintigraphy show osteoid osteoma. (c, d) CT scans obtained (c) during ILP procedure and (d) 6 months after ILP.
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Figure 66b. Case 4. Osteoid osteoma of thoracic spine (T7). (a) CT scan and (b) scintigraphy show osteoid osteoma. (c, d) CT scans obtained (c) during ILP procedure and (d) 6 months after ILP.
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Figure 66c. Case 4. Osteoid osteoma of thoracic spine (T7). (a) CT scan and (b) scintigraphy show osteoid osteoma. (c, d) CT scans obtained (c) during ILP procedure and (d) 6 months after ILP.
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Figure 66d. Case 4. Osteoid osteoma of thoracic spine (T7). (a) CT scan and (b) scintigraphy show osteoid osteoma. (c, d) CT scans obtained (c) during ILP procedure and (d) 6 months after ILP.
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Case 5. Osteoid osteoma of the tibia (Fig 67) treated with ILP after drilling under CT (Fig 68) and fluoroscopic (Fig 69) guidance.
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Percutaneous Cementoplasty
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Introduction
Percutaneous cementoplasty with acrylic cement (polymethylmethacrylate), also referred to as vertebral packing or vertebroplasty, is a procedure aimed at preventing vertebral body crushing and pain in patients with pathologic vertebral bodies. Percutaneous cementoplasty seems to be promising in pain therapy for patients with bone failure.
Principle
The pain-reducing effect of cement cannot be explained by consolidation of the pathologic bone alone. In fact, good pain relief is obtained after injection of only 2 mL of cement in a metastasis (Fig 70). In these cases, the consolidation effect is minimal. The acrylic cement is cytotoxic because of its chemical and thermal effects during polymerization. The temperature during polymerization is high enough to produce coagulation of tumoral cells. Therefore, good pain relief can be obtained with a small volume of cement.
Indications and Contraindications
Indications
- Symptomatic vertebral angioma
- The best indication is a painful vertebral body tumor (particularly metastasis and myeloma), especially when there is a risk of compression fracture.
- Severe, painful osteoporosis with loss of height or compression fracture of the vertebral body or both
Contraindications
- Hemorrhagic diathesis
- Infection
- Lesions with epidural extension require careful injection to prevent epidural overflow and spinal cord compression by the cement.
Technique
Overview
The procedure is performed under local anesthesia, usually combined with neuroleptanalgesia. The patient is placed in the prone position for the lumbar level and in the supine position for the cervical level. A 15-gauge needle is used at the cervical level and a 10-gauge needle at the thoracic and lumbar levels (Fig 71). We always use dual guidance: CT and C-arm fluoroscopy. The entry point and the pathway are determined with CT, avoiding the nerve root and visceral structures. The needle is safely guided under CT.
Once the needle is in the optimal position, the imaging mode is switched to fluoroscopy. The acrylic cement is mixed with tantalum (to increase radio-opacity) and must be injected during its pasty polymerization phase to prevent distal venous migration. The injection of cement is carefully controlled under strict lateral fluoroscopy. The injection is stopped whenever an epidural or paravertebral opacification is observed.
Material (Figs 72, 73)
- 10-gauge needle for thoracic and lumbar spine and 15-gauge needle for cervical spine
- Surgical hammer
- Acrylic cement (low-viscosity polymethylmethacrylate [Howmedica Simplex; Howmedica Osteonics, Rutherford, NJ, or Palacos; Schering-Plough, Kenilworth, NJ])
- Pressure syringe (Optimed) to facilitate the injection of this viscous cement
- 2 g tantalum or tungsten (acrylic cement is not radio-opaque enough)
- Sterile drapes, tampons
Dual Guidance
Percutaneous cementoplasty, like other interventional procedures, is usually performed with a single imaging technique: fluoroscopy or CT, both of which have advantages and drawbacks. Fluoroscopy offers multiple planes and direct imaging, with the disadvantages of poor soft-tissue contrast and nonnegligible radiation exposure for both patient and operator. CT is well suited for precise interventional needle guidance because it provides good visualization of bone and surrounding soft tissue. It also avoids damage to adjacent vascular, nerve, and visceral structures. The disadvantages of this method are single-plane and delayed imaging.
To address these concerns on a routine basis, a combination of CT and fluoroscopy for interventional procedures has been recommended. For fluoroscopy, a mobile C-arm is used, positioned in front of the CT gantry (Fig 5). By using a rotating fluoroscope and CT, the structure to be punctured can be visualized three dimensionally and with exact differentiation of anatomic structures, which in many cases is not possible with fluoroscopy alone. Two mobile monitors were placed in front of the physician, displaying the last stored image and the fluoroscopic image. The operator can switch from CT to fluoroscopy and vice versa at any time.
In percutaneous vertebroplasty, the intervention begins with CT and is followed by fluoroscopy. The needle is placed precisely and safely under CT guidance (Fig 6); the injection of the acrylic cement requires real-time imaging and is therefore performed under fluoroscopic guidance. This combination has many advantages and the possibilities are almost unlimited, making possible other applications in interventional radiology.
Local Anesthesia
The procedure is performed under local anesthesia, usually combined with neuroleptanalgesia. The skin, subcutaneous layers, muscles, and periosteum are infiltrated with local anesthetic (1% lidocaine ) with a 9-cm-long, 22-gauge needle.
Puncture
After positioning the patient, who has received under neuroleptanalgesia and local anesthesia, a 10- to 15-gauge trocar needle is introduced into the vertebral body. Different approach routes can be selected: the anterior route for the cervical level, the transpedicular and intercostovertebral routes for the thoracic level, and the posterolateral and transpedicular routes for the lumbar level (Figs 10, 11).
The needle is guided safely under CT. Cortical perforation requires the aid of a surgical hammer (Fig 74a). When the needle (Fig 74b) is in the optimal position (needle tip in the anterior third of the vertebral body), the imaging mode is switched to fluoroscopy.
Preparation of the Cement
A package of low-viscosity polymethylmethacrylate is composed of a packet consisting of 40 g of powder and a tube containing 20 mL of fluid monomer. The acrylic cement is prepared by mixing 20 g of the powder (half of the packet) and 10 mL of fluid monomer (Fig 75a). Because the cement is not sufficiently radiopaque, 2 g of tantalum is added to the mixture (Fig 75b). During the first 30-50 seconds after mixing, the glue is thin but then becomes pasty (Fig 75c). The acrylic cement must be injected during this pasty polymerization phase to prevent distal venous migration. A pressure syringe is used to facilitate the injection of 2-8 mL of the viscous mixture (Fig 75d). At this stage, the intervention has to be performed quickly because the cement begins to thicken after 3 minutes and further injection becomes impossible.
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Figure 75a. Preparation of the acrylic cement: (a) polymethylmethacrylate is mixed with monomer, (b) tantalum powder is added to the mixture, (c) the mixture is stirred, and (d) the pressure syringe is filled with the viscous cement.
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Figure 75b. Preparation of the acrylic cement: (a) polymethylmethacrylate is mixed with monomer, (b) tantalum powder is added to the mixture, (c) the mixture is stirred, and (d) the pressure syringe is filled with the viscous cement.
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Figure 75c. Preparation of the acrylic cement: (a) polymethylmethacrylate is mixed with monomer, (b) tantalum powder is added to the mixture, (c) the mixture is stirred, and (d) the pressure syringe is filled with the viscous cement.
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Figure 75d. Preparation of the acrylic cement: (a) polymethylmethacrylate is mixed with monomer, (b) tantalum powder is added to the mixture, (c) the mixture is stirred, and (d) the pressure syringe is filled with the viscous cement.
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Injection of the Cement
This phase of the procedure is guided with lateral fluoroscopy and CT (Fig 76). The injection of the acrylic cement is immediately stopped whenever an epidural or paravertebral opacification is observed in order to prevent spinal cord compression. When vertebral filling is insufficient, a contralateral approach is used to complete the filling. After the vertebral filling, the stylet of the needle is replaced and the needle removed before the cement begins to set. Six to 7 minutes after mixing, the polymethylmethacrylate begins to harden. During this hardening time, the cement becomes hot (about 90°C). The patient should be under neureuleptanalgesia to control pain. Monitoring of the arterial pressure is necessary during the procedure because acrylic cement injections can induce brief drops in arterial pressure. The total procedure time ranges from 20 to 50 minutes. In patients with osteoporosis and symptomatic hemangioma, an optimal filling (2.5-4 mL) of the vertebral body is required to obtain both effects of percutaneous vertebroplasty: consolidation and pain relief. In patients with tumoral disease, percutaneous cementoplasty is usually performed for excruciating pain. In these cases, a small volume (1.5-2.5 mL) of acrylic cement provides good pain relief.
Complications
- The major complication is a cement leak.
- A secondary complication is infection. To prevent this complication, strict sterility during the intervention is mandatory.
- Patients experience temporary pain after the procedure but are usually free of symptoms after 24 hours. The postprocedural pain is usually proportional to the volume of cement injected. The majority of the patients had good packing of the vertebral body with more than 4 mL of acrylic cement injected.
- The risk of allergic reactions and hypertension is limited in these procedures because the quantities of acrylic cement injected are far smaller than those used in orthopedic surgery.
Cement Leaks (Fig 77)
- Cement leaks into epidural veins, the epidural space, and the neural foramina: The major complication is epidural overflow of the cement, with spinal cord compression. This risk is minimized by monitoring the bone filling with a high-quality fluoroscopy unit and by adequate radiopacity (tantalum) of the acrylic cement. Radiculopathy is the major risk with neural foramina leaks. In our series, three complications occurred immediately after cementoplasty: The filling of an epidural vein and neural foramina caused intercostal neuralgia. This complication can be successfully treated with a series of intercostal steroid infiltrations. In case of a complication, orthopedic or neurosurgical support should be available. Epidural vein filling does not systematically cause neuralgia.
- Cement leaks toward the disk (Fig 78): These leaks are usually without clinical consequences; however, these leaks may increase the risk of collapse of adjacent vertebrae.
- Leaks into paravertebral veins (Fig 79) can lead to pulmonary cement embolism (Fig 80). In our series, an asymptomatic pulmonary embolism was detected in two cases. In both cases, paravertebral venous opacification was observed. To prevent major pulmonary infarction, the cement should be injected slowly under fluoroscopic guidance during its pasty polymerization phase, and the injection should be immediately stopped if a venous leak is observed.
- Cement leaks into paravertebral soft tissues have no clinical significance.
- In one case, the postprocedure CT scan showed a leak of acrylic cement into an intercostal artery. This leak was asymptomatic.
- Leaks into the epidural space (Fig 81a) can cause intercostal neuralgia (Fig 81b).
Results
From 1990 to 1999, we performed percutaneous cementoplasty in 187 patients. Indications included severe painful osteoporosis (105 patients), vertebral tumors (myeloma and metastasis, 69 patients), symptomatic hemangiomas (11 patients), and postoperative decompression (two patients). A total of 289 vertebral bodies underwent injection (mean, 1.54 vertebrae per patient). The average volume of cement injected was 2.8 mL (range, 1.8-6.5 mL). The analgesic effect appeared within 12-48 hours after the procedure. The results were evaluated according to the reduction of opiate analgesic doses required (Table 3). Satisfactory results (pain score, 2 or greater were obtained in 146 (79%) of the patients. An analgesic score of 3 or greater was achieved in 133 (71%) of the patients. Percutaneous cementoplasty is a successful technique for pain management and consolidation of pathologic vertebral bodies. The most critical elements for successful vertebroplasty are proper patient selection, correct needle placement, proper timing of cement injection, strict fluoroscopic guidance, and operator's experience. The good pain relief obtained with this technique does not correlate with the volume of cement injected, especially in metastasis, in which 1.5 mL of cement is usually enough to considerably reduce the patient's pain.
Osteoporosis (105 Cases)
Satisfactory results (pain score greater than or equal to 2) were obtained in 82 (78%) of the cases on the basis of reduction of analgesics doses. Maximum follow-up time was 7 years (mean, 2.7 years).
Vertebral Tumors (69 Cases)
Satisfactory results (pain score greater than or equal to 2) were obtained in 57 (83%) of the cases. Maximum follow-up time was 1.2 years (mean, 7 months).
Hemangiomas (11 Cases)
Satisfactory results (pain score greater than or equal to 2) were obtained in eight (73%) of the cases. Maximum follow-up time was 6 years (mean, 3.8 years). In three cases with epidural extension and neurologic complications, percutaneous vertebroplasty was performed first and the surgical intervention for epidural decompression was done in a second phase.
Cases
Case 1. Percutaneous cementoplasty via the intercostovertebral route for aggressive vertebral angioma (Fig 82). A bilateral approach was used, and there were no complications.
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Figure 82a. Case 1. Aggressive vertebral angioma. (a-d) CT scans show (a) angioma, (b) needle path and (c) puncture, and (d) result of procedure. (e) Fluorosopic guidance during procedure.
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Figure 82b. Case 1. Aggressive vertebral angioma. (a-d) CT scans show (a) angioma, (b) needle path and (c) puncture, and (d) result of procedure. (e) Fluorosopic guidance during procedure.
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Figure 82c. Case 1. Aggressive vertebral angioma. (a-d) CT scans show (a) angioma, (b) needle path and (c) puncture, and (d) result of procedure. (e) Fluorosopic guidance during procedure.
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Figure 82d. Case 1. Aggressive vertebral angioma. (a-d) CT scans show (a) angioma, (b) needle path and (c) puncture, and (d) result of procedure. (e) Fluorosopic guidance during procedure.
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Figure 82e. Case 1. Aggressive vertebral angioma. (a-d) CT scans show (a) angioma, (b) needle path and (c) puncture, and (d) result of procedure. (e) Fluorosopic guidance during procedure.
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Case 2. Percutaneous cementoplasty at five levels via the intercostovertebral route for severe osteoporosis with loss of height and with several compression fractures of vertebral bodies (Fig 83). There were no complications.
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Figure 83a. Case 2. Severe osteoporosis with compression fractures of vertebral bodies. (a, b) Puncture performed under (a) CT and (b) fluoroscopic guidance. (c) Cement injection under fluorscopic guidance. (d, e) Results of procedure seen at (d) CT and (e) fluoroscopy.
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Figure 83b. Case 2. Severe osteoporosis with compression fractures of vertebral bodies. (a, b) Puncture performed under (a) CT and (b) fluoroscopic guidance. (c) Cement injection under fluorscopic guidance. (d, e) Results of procedure seen at (d) CT and (e) fluoroscopy.
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Figure 83c. Case 2. Severe osteoporosis with compression fractures of vertebral bodies. (a, b) Puncture performed under (a) CT and (b) fluoroscopic guidance. (c) Cement injection under fluorscopic guidance. (d, e) Results of procedure seen at (d) CT and (e) fluoroscopy.
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Figure 83d. Case 2. Severe osteoporosis with compression fractures of vertebral bodies. (a, b) Puncture performed under (a) CT and (b) fluoroscopic guidance. (c) Cement injection under fluorscopic guidance. (d, e) Results of procedure seen at (d) CT and (e) fluoroscopy.
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Figure 83e. Case 2. Severe osteoporosis with compression fractures of vertebral bodies. (a, b) Puncture performed under (a) CT and (b) fluoroscopic guidance. (c) Cement injection under fluorscopic guidance. (d, e) Results of procedure seen at (d) CT and (e) fluoroscopy.
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Case 3. Percutaneous cementoplasty via the intercostovertebral route for severe osteoporosis (Fig 84). There were no complications.
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Figure 84a. Case 3. Severe osteoporosis. (a) Fluoroscopy shows osteoporosis. (b) Vertebral puncture under CT guidance. (c) Cement injection under fluoroscopic guidance. (d) CT scan shows results of procedure.
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Figure 84b. Case 3. Severe osteoporosis. (a) Fluoroscopy shows osteoporosis. (b) Vertebral puncture under CT guidance. (c) Cement injection under fluoroscopic guidance. (d) CT scan shows results of procedure.
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Figure 84c. Case 3. Severe osteoporosis. (a) Fluoroscopy shows osteoporosis. (b) Vertebral puncture under CT guidance. (c) Cement injection under fluoroscopic guidance. (d) CT scan shows results of procedure.
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Figure 84d. Case 3. Severe osteoporosis. (a) Fluoroscopy shows osteoporosis. (b) Vertebral puncture under CT guidance. (c) Cement injection under fluoroscopic guidance. (d) CT scan shows results of procedure.
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Case 4. Percutaneous cementoplasty via the transpedicular route for vertebral angioma (Fig 85).
Case 5. Percutaneous cementoplasty with 3.5 mL of cement via the transpedicular route for painful metastases (Fig 86). Good pain relief was achieved with no complications.
Case 6. Percutaneous cementoplasty with 2.5 mL of cement via the posterolateral route for painful metastases (Fig 87). There were no complications.
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Figure 87a. Case 6. Osteolytic metastases. (a, b) CT scans show (a) metastasis and (b) vertebral puncture. (c, d) Cement injection under fluoroscopic guidance. (e) CT scan shows results of procedure.
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Figure 87b. Case 6. Osteolytic metastases. (a, b) CT scans show (a) metastasis and (b) vertebral puncture. (c, d) Cement injection under fluoroscopic guidance. (e) CT scan shows results of procedure.
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Figure 87c. Case 6. Osteolytic metastases. (a, b) CT scans show (a) metastasis and (b) vertebral puncture. (c, d) Cement injection under fluoroscopic guidance. (e) CT scan shows results of procedure.
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Figure 87d. Case 6. Osteolytic metastases. (a, b) CT scans show (a) metastasis and (b) vertebral puncture. (c, d) Cement injection under fluoroscopic guidance. (e) CT scan shows results of procedure.
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Figure 87e. Case 6. Osteolytic metastases. (a, b) CT scans show (a) metastasis and (b) vertebral puncture. (c, d) Cement injection under fluoroscopic guidance. (e) CT scan shows results of procedure.
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Case 7. Percutaneous cementoplasty via the transpedicular route for osteolytic hypervascular breast cancer metastasis (Fig 88). There was a cement leak in the intercostal artery.
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Figure 88a. Case 7. Osteolytic hypervascular breast cancer metastasis. CT scans show (a) injection of local anesthetic, (b) vertebral puncture, and (c) intercostal artery leak (arrow) after procedure.
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Figure 88b. Case 7. Osteolytic hypervascular breast cancer metastasis. CT scans show (a) injection of local anesthetic, (b) vertebral puncture, and (c) intercostal artery leak (arrow) after procedure.
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Figure 88c. Case 7. Osteolytic hypervascular breast cancer metastasis. CT scans show (a) injection of local anesthetic, (b) vertebral puncture, and (c) intercostal artery leak (arrow) after procedure.
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Case 8. Percutaneous cementoplasty at two levels via the intercostovertebral route for severe osteoporosis (Fig 89). There was a minimal venous leak.
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Figure 89a. Case 8. Severe osteoporosis. (a-c) Fluoroscopy shows (a) vertebral puncture, (b) cement injection, and (c) results of procedure. (d) CT scan shows minimal venous leak (arrow) after procedure.
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Figure 89b. Case 8. Severe osteoporosis. (a-c) Fluoroscopy shows (a) vertebral puncture, (b) cement injection, and (c) results of procedure. (d) CT scan shows minimal venous leak (arrow) after procedure.
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Figure 89c. Case 8. Severe osteoporosis. (a-c) Fluoroscopy shows (a) vertebral puncture, (b) cement injection, and (c) results of procedure. (d) CT scan shows minimal venous leak (arrow) after procedure.
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Figure 89d. Case 8. Severe osteoporosis. (a-c) Fluoroscopy shows (a) vertebral puncture, (b) cement injection, and (c) results of procedure. (d) CT scan shows minimal venous leak (arrow) after procedure.
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Case 9. Percutaneous cementoplasty with 3.5 mL of cement via the intercostovertebral route for painful metastases (Fig 90). Good pain relief was achieved with no complications.
Case 10. Percutaneous cementoplasty at the C4 level via the anterior route for myeloma (Fig 91). There was a minimal diskal leak at C3-C4
Case 11. Percutaneous cementoplasty via the intercostovertebral route for aggressive vertebral angioma (Fig 92). Surgical intervention for epidural decompression was done in a second phase.
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Figure 92a. Case 11. Aggressive vertebral angioma. (a, b) Angioma seen at (a) CT and (b) MR imaging. (c) CT venography of angioma. (d, e) CT scans of (d) vertebral puncture and (e) results of procedure.
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Figure 92b. Case 11. Aggressive vertebral angioma. (a, b) Angioma seen at (a) CT and (b) MR imaging. (c) CT venography of angioma. (d, e) CT scans of (d) vertebral puncture and (e) results of procedure.
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Figure 92c. Case 11. Aggressive vertebral angioma. (a, b) Angioma seen at (a) CT and (b) MR imaging. (c) CT venography of angioma. (d, e) CT scans of (d) vertebral puncture and (e) results of procedure.
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Figure 92d. Case 11. Aggressive vertebral angioma. (a, b) Angioma seen at (a) CT and (b) MR imaging. (c) CT venography of angioma. (d, e) CT scans of (d) vertebral puncture and (e) results of procedure.
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Figure 92e. Case 11. Aggressive vertebral angioma. (a, b) Angioma seen at (a) CT and (b) MR imaging. (c) CT venography of angioma. (d, e) CT scans of (d) vertebral puncture and (e) results of procedure.
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Case 12. Percutaneous acetabular cementoplasty, done with the same technique as for vertebroplasty, for painful metastases (Fig 93). Good pain relief was achieved with no complications.
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Figure 93a. Case 12. Osteolytic metastases in acetabulum. (a, b) Metastases seen at (a) CT and (b) fluoroscopy. (c, d) Acetabular cementoplasty under (c) CT and (d) fluoroscopic guidance. (e) CT scan shows results of procedure.
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Figure 93b. Case 12. Osteolytic metastases in acetabulum. (a, b) Metastases seen at (a) CT and (b) fluoroscopy. (c, d) Acetabular cementoplasty under (c) CT and (d) fluoroscopic guidance. (e) CT scan shows results of procedure.
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Figure 93c. Case 12. Osteolytic metastases in acetabulum. (a, b) Metastases seen at (a) CT and (b) fluoroscopy. (c, d) Acetabular cementoplasty under (c) CT and (d) fluoroscopic guidance. (e) CT scan shows results of procedure.
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Figure 93d. Case 12. Osteolytic metastases in acetabulum. (a, b) Metastases seen at (a) CT and (b) fluoroscopy. (c, d) Acetabular cementoplasty under (c) CT and (d) fluoroscopic guidance. (e) CT scan shows results of procedure.
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Figure 93e. Case 12. Osteolytic metastases in acetabulum. (a, b) Metastases seen at (a) CT and (b) fluoroscopy. (c, d) Acetabular cementoplasty under (c) CT and (d) fluoroscopic guidance. (e) CT scan shows results of procedure.
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Case 13. Percutaneous acetabular cementoplasty, done with the same technique as for vertebroplasty, for painful metastases (Fig 94). Good pain relief was achieved with no complications.
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Figure 94a. Case 13. Osteolytic metastases in acetabulum. (a) CT scan shows acetabular metastases. (b, c) Puncture of acetabulum under (b) CT and (c) fluoroscopic guidance. (d) Injection of cement under fluoroscopic guidance. (e, f) Results of procedure seen at (e) CT and (f) fluoroscopy.
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Figure 94b. Case 13. Osteolytic metastases in acetabulum. (a) CT scan shows acetabular metastases. (b, c) Puncture of acetabulum under (b) CT and (c) fluoroscopic guidance. (d) Injection of cement under fluoroscopic guidance. (e, f) Results of procedure seen at (e) CT and (f) fluoroscopy.
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Figure 94c. Case 13. Osteolytic metastases in acetabulum. (a) CT scan shows acetabular metastases. (b, c) Puncture of acetabulum under (b) CT and (c) fluoroscopic guidance. (d) Injection of cement under fluoroscopic guidance. (e, f) Results of procedure seen at (e) CT and (f) fluoroscopy.
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Figure 94d. Case 13. Osteolytic metastases in acetabulum. (a) CT scan shows acetabular metastases. (b, c) Puncture of acetabulum under (b) CT and (c) fluoroscopic guidance. (d) Injection of cement under fluoroscopic guidance. (e, f) Results of procedure seen at (e) CT and (f) fluoroscopy.
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Figure 94e. Case 13. Osteolytic metastases in acetabulum. (a) CT scan shows acetabular metastases. (b, c) Puncture of acetabulum under (b) CT and (c) fluoroscopic guidance. (d) Injection of cement under fluoroscopic guidance. (e, f) Results of procedure seen at (e) CT and (f) fluoroscopy.
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Figure 94f. Case 13. Osteolytic metastases in acetabulum. (a) CT scan shows acetabular metastases. (b, c) Puncture of acetabulum under (b) CT and (c) fluoroscopic guidance. (d) Injection of cement under fluoroscopic guidance. (e, f) Results of procedure seen at (e) CT and (f) fluoroscopy.
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Abstract
Biopsies of the Musculoskeletal...
